Cannabis use was associated with a significant twofold increased risk for major adverse cardiovascular events (MACEs), including a doubling in the likelihood of death from these events, a meta-analysis of 24 relevant studies has found.
The analysis is one of the largest and most detailed to date examining cannabis use and MACEs in real-world settings, reports Medscape, and based on their findings, the authors have called for “systematic investigation” of cannabis use in all patients presenting with serious cardiovascular disorders.
The study, with first author Wilhelm Storck, PhD, with the University of Toulouse, France, was published in The BMJ Heart.
Changing attitudes
The findings come at a time of increasing cannabis use, driven in part by legalisation and the expanding use of cannabis for medical purposes – shifts that may have contributed to more permissive public attitudes toward the drug, despite accumulating evidence of potential risk to heart health.
Previous studies have described potential cannabis-related cardiovascular risk. But knowledge gaps remained on the magnitude of the associated risk for cannabis users, particularly in recent years marked by the availability of more potent and increasingly diverse forms of cannabis, from high-strength inhaled concentrates to edibles and synthetic cannabinoids.
Storck and colleagues sought to quantify the actual cardiovascular risks of cannabis use amid these evolving trends.
They systematically reviewed 24 pharmacoepidemiologic studies (17 cross-sectional, six cohort, and one case-control study) published between January 2016 and January 2023. Combined, the studies involved roughly 200m individuals across multiple countries.
The final analysis focused on cannabis-related MACEs (i.e, cardiovascular death; non-fatal acute coronary syndrome (ACS), including myocardial infarction; or non-fatal stroke).
Their pooled results revealed positive associations between cannabis use and MACEs, with a 20% higher risk for stroke (risk ratio [RR], 1.20), a 29% higher risk for ACS (RR, 1.29), and more than double the risk for cardiovascular mortality (RR, 2.10) compared with non-users.
The investigators noted that the single study on medical cannabis that was included in the meta-analysis also highlighted a positive association.
The findings held up in sensitivity analyses limited to cohort studies, suggesting a robust association despite some methodological limitations, the authors said.
In addition, they noted that four additional papers published outside the time window of their study yielded comparable results.
Treat cannabis like tobacco?
The authors wrote that cannabis exposure was often poorly measured across the studies. Only four studies collected data on dose and assessed dose-response. There was also a moderate-to-high risk for bias in many of the studies.
Most studies were cross-sectional, which are not designed to prove causality.
Despite these caveats, this “exhaustive analysis of published data on the potential association between cannabis use and the occurrence of MACE provides new insights from real-world data”, they said.
The authors of a linked editorial said the study raises “serious questions about the assumption that cannabis poses little cardiovascular risk.”
“Cannabis needs to be incorporated into the framework for prevention of clinical cardiovascular disease. So too must cardiovascular disease prevention be incorporated into the regulation of cannabis markets,” wrote Stanton Glantz, PhD, and Lynn Silver, MD, MPH, from the University of California-San Francisco.
As the evidence base grows, Glantz and Sliver said cardiovascular and other health risks must be considered in the regulation of allowable product and marketing design.
“Today that regulation is focused on establishing the legal market with woeful neglect of minimising health risks. Specifically, cannabis should be treated like tobacco: Not criminalised but discouraged, with protection of bystanders from second-hand exposure,” they concluded.
Study details
Cardiovascular risk associated with the use of cannabis and cannabinoids: a systematic review and meta-analysis
Wilhelm Storck, Meyer Elbaz, Cécile Vindis, Amélia Déguilhem, Maryse Lapeyre-Mestre, Emilie Jouanjus.
Published in The BMJ Heart in June 2025
Abstract
Background
Awareness has recently risen about the potential associated risks to the cardiovascular health of cannabis users. The objective was to evaluate the possible association between major adverse cardiovascular events (MACE) and the use of cannabis or cannabinoids.
Methods
Original pharmacoepidemiological studies providing risk estimates on cannabis-related MACE (ie, cardiovascular death, non-fatal acute coronary syndrome (ACS) including myocardial infarction (MI) or non-fatal stroke) published from 1 January 2016 to 31 January 2023 were included in the systematic review exploring PubMed, Web of Science and Scopus (last search: 20 September 2023). Design, duration, baseline characteristics, exposure, inclusion criteria, sample size, effect size and confusing factors, including exposure to psychoactive substances, were extracted. Study quality was assessed using the ROBINS-E (risk of bias in non-randomised studies—of exposures) tool. In the meta-analysis, adjusted effect estimates and their 95% CIs were pooled using a DerSimonian and Laird random effect model with inverse variance weighting based on the type of outcome (PROSPERO: CRD42023401401).
Results
Overall, 24 articles were included from 3012 initial records, including 17 cross-sectional studies, 6 cohort studies and 1 case-control study. Exposure corresponded to the use of cannabis in all studies, with one focused on medical cannabis. The estimated risk ratio (RR) was 1.29 (95% CI 1.05 to 1.59) for ACS, 1.20 (1.13 to 1.26) for stroke and 2.10 (1.29 to 3.42) for cardiovascular death. As measured in two studies, no statistically significant association was found for the composite outcome combining ACS and stroke. The focused analysis restricted to cohort studies yielded comparable results to the primary model (RR=1.32, 1.01 to 1.73).
Conclusions
This systematic review and meta-analysis uses an original approach centred on real-world data. The findings reveal positive associations between cannabis use and MACE. These findings should encourage investigating cannabis use in all patients presenting with serious cardiovascular disorders.
See more from MedicalBrief archives:
Cannabis use poses cardiovascular risk – US study
Frequent cannabis use bumps up heart attack risk – US study
Cannabis linked to heart disease, supplement may mitigate risk – Stanford